Peers in Co-Occurring Services: Impact on Fidelity. Jennifer Harrison, LMSW, CAADC

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1 Peers in Co-Occurring Services: Impact on Fidelity Jennifer Harrison, LMSW, CAADC

2 Introduction

3 Co-Occurring Disorders >50% with a Serious Mental Illness (SMI) also have a Substance Use Disorder (SUD) million Americans have both SMI and SUD 1 Outcomes for CODs are worse in: Incarceration Hospitalization Homelessness Unemployment Health 2,3

4 Evolution of Co-Occurring Care 4,5 SUD SUD care MH care SUD care MH care PARALLEL CARE SEQUENTIAL CARE SUD and MH MH care INTEGRATED CARE

5 Introduction: IDDT Integrated Dual Disorder Treatment: Evidence-Based Practice for adults with severe co-occurring mental illness and substance use disorder Full multi-disciplinary team Stage-matched interventions Motivational interviewing Family education Active outreach (McHugo, et al., 2007) Fidelity has 26 measures (12 organizational and 14 treatment) High fidelity is associated with improved outcomes (McHugo, et al, 2007, Chandler, 2011)

6 IDDT in Michigan 2005

7 Fidelity knowing it s done right Fidelity is fit of actual practice to evidence-based model High fidelity - improved outcomes 7 Fidelity improves over time 8

8 Importance

9 Introduction: Peers Peers = Qualified Mental Health Professionals (QMHP) with lived recovery experience of serious mental illness Small effect on psychiatric re-hospitalization in adults with mental illness was seen in the peer services group 8 Co-occurring individuals with recent hospitalization had longer community tenure using survival analysis when receiving peer services, and were significantly less likely to be hospitalized in a three year timeframe (62%) when matched to their nonpeer service comparison group (73%) 5

10 IDDT + peers 2007

11 Research Questions 1. Does IDDT fidelity change over time with a practice alteration? 2. Does any change over time of IDDT fidelity differ for teams with peers and teams without peers?

12 Methods

13 Study Sample Fidelity review data of all IDDT teams in Michigan from yearly reviews 68 teams Peer team member data self-report from IDDT team leaders

14 Variables Variable (# of cases) Range (Mean/SD) Variable type Review Year (122) 1-7 Predictor/Ordinal Peer (33) 0-1 Predictor/Dichotomous FTE of Peer (None, PT, FT)(33) 1-3 Predictor/Ordinal Total fidelity (122) (3.57/.70) Outcome/Continuous

15 Statistical Analysis Descriptive, binomial, ANOVA, and linear regression - SPSS v. 20 Hierarchical linear modeling - HLM 11 Alpha level set at.05

16 Choice of HLM Team 2 Team 2 review FY 08 no peer Team 2 review FY 11 no peer Team 1 Team 1 review FY 07 FT peer Team 1 review FY 09 FT peer Team 1 review FY 11 PT peer

17 Results

18 Table 1: IDDT Team Characteristics (Num of Reviews=137, 26.3% reporting on peer team characteristics) (Michigan Fidelity Assessment and Support Team, 2013) Team Characteristics (N=137) Yes Team Peer Characteristics (N=36) Yes Assertive Community Treatment 107 (78.1%) Had a peer 29 (80.6%) Rural 55 (40.1%) Had a certified peer 24 (66.7%) Had a full-time peer 11 (30.6%) Had more than 1 peer 6 (16.7%)

19 Results: Fidelity Items Table 2: IDDT Fidelity Items high and low (N=137, range = , Mean = 3.57, Standard Deviation =.71) (MiFAST, 2013) Low fidelity items Mean (SD) High fidelity items Mean (SD) Penetration 2.21 (1.27) Substance Abuse Specialist 4.46 (.75) Self-Help Liaisoning 2.47 (1.26) Multi-disciplinary team 4.36 (.73) Outreach 4.36 (.75) Long-Term Services 4.36 (.75)

20 Figure 1: IDDT reviews by year

21 IDDT fidelity over time one way ANOVA (N=122) (MiFAST, 2013) (F-score=1.87; p <.05) YR1 YR2 YR3 YR4 YR5 YR6 YR7

22 Frequency of Peers on IDDT teams (N=33) (MiFAST, 2013) % Yes Peer Certified Peer Full-time Peer >1 Peer

23 One-Way ANOVA of peer and model fidelity (N- 33) (MiFAST, 2013) (f-score = 6.40, p<.01) No Peer (5) PT Peer (17) FT Peer (11)

24 Multi-level Model of IDDT Total Fidelity Scores over time with full-time peer (MiFAST, 2013) (N=33) Final Fixed Effects Coefficient Standard Error Test Statistic (t-ratio) df Sig. Intercept (total fidelity) p <.001 Slope (year) p <.001 Slope (full-time peer) p =.062

25 Discussion

26 Peers, Fidelity, and Time IDDT improves over time Ever having a full-time peer is associated with higher fidelity Over time within teams, full time peer not associated with fidelity Power issues with HLM

27 Limitations Response rate 27% for peer team data Total team staffing Teams with high fidelity hire peers

28 Further Research Effect of peers on clinical outcomes directly Factorial analysis of peers on individual fidelity items, and individual fidelity items on clinical outcomes Qualitative analysis of the experience of being a peer specialist

29 Acknowledgements To the WMU Interdisciplinary Health Sciences PhD Program and Amy Curtis, PhD, Nickola Nelson, PhD & Kieran Fogarty, PhD, for support of interdisciplinary research To MiFAST reviewers and IDDT team leaders for sharing information about their work for further learning To peers in Michigan for their courage in sharing their recovery with others To my family, friends, and colleagues for being so darn sweet

30 References 1. Kendler, K. S., Gallagher, T. J., & Abelson, J. M. (1996). Lifetime prevalence, demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in a US community sample: the National Comorbidity Survey. Archives of General Psychiatry, 53, Frisman, L. K., Mueser, K. T., Covell, N. H., Lin, H., Crocker, A., Drake, R. E., & Essock, S. M. (2009). Use of integrated dual disorder treatment via assertive community treatment versus clinical case management for persons with co-occurring disorders and antisocial personality disorder. Journal of Nervous and Mental Disease, 197(11), Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, NY: The Guilford Press. 4. Drake RE, Mercer-McFadden C, & Mueser KT (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin 24, Drake, R.E., O Neal, E.L., and Wallach, M.A. (2008). A systematic review of psychosocial research on psychosocial interventions for people with co-occurring mental and substance use disorders. Journal of Substance Abuse Treatment, 34, McHugo, G. J., Drake, R. E., Whitley, R., Bond, G. R., Campbell, K., Rapp, C. A., & Finnerty, M. T. (2007). Fidelity outcomes in the national implementing evidence-based practices project. Psychiatric Services, 58(10), Chandler, D. W. (2011). Fidelity and outcomes in six integrated dual disorders treatment programs. Community Mental Health Journal, 47(1), Peterson, A.E., Bond, G.R., Drake, R.E., McHugo, G.J., Jones, A.M., and Williams, J.R. (2013). Predicting the Long-Term Sustainability of Evidence-Based Practices in mental Health Care: An 8-Year Longitudinal Study. Journal of Behavioral Health Services and Research, Sledge, W. H., Lawless, M., Sells, D., Wieland, M., O'Connell, M. J., & Davidson, L. (2011). Effectiveness of peer support in reducingreadmissions of persons with multiple psychiatric hospitalizations. Psychiatric Services, 62(5), Min, S. Y., Whitecraft, J., Rothbard, A. B., and Salzer, M. S. (2007). Peer support for persons with co-occurring disorders and community tenure: A survival analysis. Psychiatric Rehabilitation, 30(3), Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models : Applications and data analysis methods (2nd ed.). Thousand Oaks, CA: Sage Publications.

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